Vertebral artery pexy for microvascular decompression of the facial nerve in the treatment of hemifacial spasm

Clinical article

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Hemifacial spasm (HFS) is caused by arterial or venous compression of cranial nerve VII at its root exit zone. Traditionally, microvascular decompression of the facial nerve has been an effective treatment for posterior inferior and anterior inferior cerebellar artery as well as venous compression. The traditional technique involves Teflon felt or another construct to cushion the offending vessel from the facial nerve, or cautery and division of the offending vein. However, using this technique for severe vertebral artery (VA) compression can be ineffective and fraught with complications. The authors report the use of a new technique of VA pexy to the petrous or clival dura mater in patients with HFS attributed to a severely ectatic and tortuous VA, and detail the results in a series of patients.


Six patients with HFS due to VA compression underwent a retrosigmoid craniotomy, combined with a far-lateral approach in some patients. On identification of the site of VA compression, the vessel was mobilized adequately for the decompression. Great care was taken to avoid kinking the perforating vessels arising from the VA. Two 8-0 nylon sutures were passed through to the wall of the VA and then through the clival or petrous dura, and then tied to alleviate compression on cranial nerve VII.


Patients were followed for at least 1 year postoperatively (mean 2.7 years, range 1–4 years). All 6 patients had complete resolution of their HFS. Facial function was tested postoperatively, and was stable when compared with the preoperative baseline. Two of the 3 patients with preoperative tinnitus had resolution of this symptom after the procedure. Postoperative imaging demonstrated VA decompression of the facial nerve and no evidence of stroke in all patients. One patient suffered from hearing loss, another developed a postoperative transient unilateral vocal cord paralysis, and a third patient developed a pseudomeningocele that resolved with the placement of a lumbar drain.


Hemifacial spasm and other neurovascular syndromes are effectively treated by repositioning the compressing artery. Careful study of the preoperative MR images may identify a select group of patients with HFS due to an ectatic VA. Rather than traditional decompression with only pledget placement, these patients may benefit from a VA pexy to provide an effective, safe, and durable resolution of their symptoms while minimizing surgical complications.

Abbreviations used in this paper: AICA = anterior inferior cerebellar artery; CN = cranial nerve; HFS = hemifacial spasm; MVD = microvascular decompression; PICA = posterior inferior cerebellar artery; RExZ = root exit zone; SCA = superior cerebellar artery; VA = vertebral artery.

Article Information

Address correspondence to: Laligam N. Sekhar, M.D., Department of Neurosurgery, Harborview Medical Center, University of Washington School of Medicine, Box 359924, 325 Ninth Avenue, Seattle, Washington 98104-2499. email:

Please include this information when citing this paper: published online January 28, 2011; DOI: 10.3171/2010.12.JNS10891.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Axial MR images and intraoperative photographs obtained in a patient undergoing VA pexy for HFS. Preoperative (A) and postoperative (B) axial T2-weighted sequence MR imaging slices demonstrating the region of vertebral compression of the facial nerve's RExZ. The postoperative MR image illustrates the decompression after pexy of the VA. The intraoperative photographs show the degree of VA compression of the facial nerve before (C) and after (D) pexy in the same patient.

  • View in gallery

    Schematic series showing the MVD technique of VA pexy to the adjacent dura mater for severe compression of the facial nerve. The initial view of the VA along the RExZ is shown (upper). Notice the displacement of the RExZ to a location ventral to the lateral brainstem. The surgical technique is illustrated schematically in the lower panel. The inset illustrates the assistant gently holding the VA close to the dura, while the surgeon sutures the VA to it. After the pexy technique, the decompression of the nerve is obvious. BA = basilar artery.


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